The saying goes, "If it's not broken, don't fix it." But I've found that in many aspects of patient care, something is almost always broken and needs fixing -- even if we don't realize it. At first glance, the contact lens daily wear model appears sound. But if we examine it and listen carefully to our daily wear patients, then it's obvious that this model is overdue for repair.

Daily wear continues as the dominant prescribed schedule by a wide margin: Of total dispenses in 2003, 90 percent were daily wear and 10 percent were extended wear. The ratio varies according to practice location, but even in our Washington, D.C. office, in which many patients have shown interest in longer-term vision correction such as laser surgery and continuous wear
(CW), the great majority of them still wear two-week daily wear lenses.

Why Daily Wear Endures

Several reasons exist for daily wear's continued dominance, starting with the inherent virtues of this model: The eyes get a rest from lens wear every night, and patients remove any contaminants on or under the lenses every day. Traditional hydrogel lens benefits also play a role: They're hydrophilic, flexible and frequently replaced (most commonly every two weeks), as well as cost effective for most patients.

And don't forget that CW isn't for everybody. Entire categories of patients are poor CW candidates, including those who have a history of microbial keratitis or external eye disease, those who have allergies that require topical medication not intended for use during lens wear and those who are exposed to large amounts of dirt, chemicals or other contaminants in their daily environment. Individual patients may also prove unsuited to CW for a variety of reasons such as poor tear quality or allergies.

Defining the Critical Flaw

Why is the daily wear model broken? Discomfort, specifically end-of-day dryness, is the biggest reason. This problem doesn't just affect certain segments of the population, such as older patients or those suffering from dry eye. In our practice, we find end-of-day dryness and discomfort issues across the board -- in 25-year-olds as often as in 60-year-olds. I attribute this to three factors:

1. Computer use, which tends to reduce blink rate

2. Dry indoor air from air conditioning and heating

3. Lens materials that patients commonly wear

A Silent Drain on Your Business

Discomfort starts as a problem for patients, but becomes a major problem for us when they drop out of lens wear -- and out of our practices. Lack of comfort is the number-one reason why patients drop out. In 2003 alone, 3.2 million patients dropped out of contact lens wear.

More than 50 percent of current contact lens wearers experience discomfort problems by the end of their day. Many patients -- even those who don't complain -- are contact lens "survivors," not satisfied wearers. These patients are on the cusp of dropping out of lens wear. They generally don't speak up about their problems; they just quietly disappear from your practice. (One clear sign that patients are leaving is when you notice your lab dollars dropping.)

You might think that if your lens-wearing patients experience discomfort, then they'll let you know, giving you the opportunity to solve their problem and keep their business. Think again. When it comes to comfort, there's a dangerous gap between your perceptions and those of your patients. The typical practitioner's perception is, "If patients don't complain, then their comfort level is adequate." Meanwhile, the patient's perception is, "Lenses become uncomfortable by the end of the day, but that's part of wearing them -- it just goes with the territory. So why complain about it?"

Digging for Problems

How can we fix the broken daily wear model and retain patients? We must first bridge the comfort-perception gap. Don't passively wait for patients to bring problems to your attention, but actively assess the comfort level of every lens wearer. You may find room for improvement even with patients who seem to tolerate their lenses well. It's our responsibility to determine whether they could be happier than they are now.

Some questions that work well in our practice are:

Are your contact lenses as comfortable at the end of the day as they are when you first put them in?

How frequently do you use rewetting drops?

Do you ever have to remove your lenses sooner than you want to because of discomfort?

Before we started asking our patients detailed questions about comfort, few of them complained. Once we started digging a little deeper, we uncovered problems we hadn't known were there. Almost all of our soft lens wearers told us that end-of-day dryness was a problem. We found that some of them had decided on their own to forego lens wear during the work week and to wear their contact lenses only on weekends -- which is a coping mechanism, not a solution.

Product Innovation Help

We need to communicate to patients that discomfort isn't an unavoidable part of wearing contact lenses, but an obstacle that we can surmount. Once we identify patients who are experiencing problems, we can take steps to improve their comfort level. We had limited options a decade ago. Today, we have access to innovative products that can make a real difference in patient comfort. The introduction of silicone hydrogel contact lenses was a step forward, and most practitioners equate silicone hydrogel lenses with CW contact lenses because of their higher rate of oxygen transmissibility. Yet these new lens materials also have the potential to bring greater comfort to daily wear patients.

In recent months, we've had great success with Acuvue Advance contact lenses with Hydraclear
(Vistakon). In my opinion, they have an edge in providing all-day comfort because they combine the best features of silicone hydrogels and traditional
hydrogels. They're made of a new material (galyfilcon A) that offers flexibility and a high level of oxygen transmissibility, and they feature
Hydraclear, Vistakon's proprietary wetting agent, at the lens surface and throughout the interior.

Acuvue Advance offers the sharp optics that our practice has come to expect from Acuvue lenses, and it uses the Acuvue 2 design, which means an easy transition for the many patients who currently wear that lens. I also like the fact that these lenses feature the highest level of ultraviolet blocking available in a soft contact lens -- 90 percent UV-A and 99 percent UV-B.

We were able to refit 100 patients into Acuvue Advance contact lenses in just six weeks. We've found that this lens works more often on the first try than many others, so we can successfully complete the fit sooner. Acuvue Advance has become our first choice for all contact lens fits -- new wearers, dissatisfied patients and even those who considered themselves satisfied with their current lenses.

The Potential Payoff

Yes, daily wear is broken, but we now have the resources to fix it. You stand to gain many rewards for doing so, including a lower dropout rate and an increase in new patients as a result of word of mouth. If your patients are satisfied, not just surviving, with their daily wear lenses, then they're more likely to entrust their entire family's vision care to you. If their teenagers need vision correction, for example, then parents will be more inclined to encourage lens wear and bring them in for fittings. They'll also continue to visit you as they age and their vision needs change.

We need to listen to our patients and use the innovative technologies at our disposal to exceed their expectations for comfort. Repairing and improving the daily wear model is essential to the happiness of our patients -- and the long-term health of our practices.

Dr. Rosenblatt has been in private group practice in Washington, DC, since 1990. His practice is nationally recognized for its contact lens expertise. He has participated in clinical investigations for new contact lenses and lens care products for many
manufacturers.